Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – http://www.alan-whiteside.com

Introduction

The consequences of Covid-19 stretch far beyond illness and death. In this blog I will look at some of these, but I begin with a personal note. On Monday we went to the James Paget Hospital,¹ which is about 45 km away from our home. I require minor, elective surgery to deal with an umbilical hernia. The National Health Service (NHS) assessed my situation and put me on the list. This trip was a ‘pre-operative assessment’ which involved being assessed by two sets of nurses, all very straight forward. At least it is now. The surgery was scheduled for the end of January but had to be delayed because of a surge in Covid-19 cases and admissions.

The hospital corridors were quiet, a notice on the front door says: ‘No visitors allowed’! All patients and staff must wear surgical masks. I had to visit two offices, but it took next to no time. The nurses say they have a sense they are over the worst of this surge. Make no mistake there are still people being admitted. On 22nd February, the local news reported four deaths at the hospital the previous day. The reality is many patients have put off attending hospital because ‘they do not want to be a bother to the NHS’ or they fear entering health facilities. There will be a huge backlog of people needing attention, and data suggests the excess mortality of the past year is due not only to Covid-19. In January 2021, Covid-19 was the main cause of death in the USA, with an average of more than 3,000 deaths per day. Heart disease is typically the number one cause of death, followed by cancer.

Back at the James Paget, a Covid-19 testing tent is set up outside the hospital. On this coming Saturday I have to be tested there, then isolate completely for three days. This means not seeing anyone other than the household, and not leaving the house or garden. I am also checking the availability of vaccines. Although the NHS is following a procedure, with nine priority groups (my cohort have not been called yet), people can check availability online and book if there are spaces. My half-sister and brother-in-law (in their nineties) and their daughter (about my age) have received their first doses. My sister, a head teacher at a primary school, has just received her first vaccination in London, and was offered a choice between Pfizer and AstraZeneca. Using the government website, I can find spots, but they are miles away.

The Numbers

Globally, as of 24th February there have been 112,158,348 cases and 2,486,405 deaths, with the US leading the pack with over 28 million cases and over 500,000 deaths. The next three countries are India, Brazil and Russia, while the UK is fourth with over four million cases and 121,536 deaths.²

Every evening the newsreaders on the main channels in the UK give the latest statistics: the number of recorded new cases; the number of hospitalisations; and the deaths of those who had a positive Covid-19 death in the last 28 days. A new figure has been added: the number of people who have received the first dose of a vaccine. Finally a figure we can be glad to see rising.

There are movements in the right direction. In the UK specifically,³ new cases peaked on 8th January at 68,053, on 22nd February the 7 day average was 11,187. The number of new deaths peaked at 1,725 on 27th January and the 7 day average on 22nd February was 480 with just 177 deaths on that day. The number of patients admitted to hospital peaked at 4,576 on 12th January (the easing of lockdown for Christmas celebration coming to haunt the nation, right on cue), on the 15th February it stood at 1,492. The number of first dose vaccines administered was 17,723,840 and 624,325 people had received the second dose. This is a remarkable achievement.

A similar picture (except for vaccinations) can be seen across the world. There are a few countries where numbers are climbing significantly. The Our World in Data map shows a week on week change of confirmed Covid-19 deaths in February.⁴ These had climbed by over 25% in Cameroon, Congo, Mauritania, Mali, Côte d’Ivoire, Ethiopia, Kenya, Uganda, Somalia and Botswana in Africa.⁵ Elsewhere there have been significant increases in Iraq, Oman, the Philippines and in Europe; Norway, Moldova and North Macedonia. In most countries the rates are falling, for example in Eswatini it fell by 59%, one of the highest falls in the world, and in South Africa the fall was 34.9%.

Why are the rates so different? This conundrum is addressed by Siddhartha Mukherjee in an excellent article in the New Yorker. In summary: there is a great deal that we do not know. Mukherjee goes through a number of explanations from social to biological but ends by saying

‘the pandemic’s most perplexing feature may turn out to be the epidemiological version of that mystery on the Orient Express: there’s no one culprit but many. With respect to the raw numbers, underreporting is an enormous problem; differences in age distribution, too, make a very deep cut, and perhaps the models must further calibrate their weightings here. Plainly, certain countries have benefitted from the strength of their public-health systems, fortified by a vigorous government response. (Our country (the USA) has suffered grievously from corresponding weaknesses.) In New Zealand, raising the drawbridges and stringently enforcing quarantines made all the difference. But to come to grips with the larger global pattern we have to look at a great many contributing factors—some cutting deeper than others, but all deserving attention’.⁶

The issue of under reporting was addressed in a recent BBC report. Only eight African countries have a compulsory death register system, by contrast, in Europe only Albania and Monaco don’t have such a register. It is, with the death data, possible to calculate excess deaths. Data for South Africa is reproduced below.⁷ It should be noted that this type of data is routinely available in developed countries and the Our World in Data website has this easily accessible.

Of course, there are still those who deny the existence of Covid-19 and, as worryingly, are opposed to vaccination. Tanzanian president John Magufuli is one such denier. He declared the country coronavirus-free last year and the government, against WHO advice and scientific consensus, rejects mask-wearing and social distancing.

‘Mr Magufuli has also warned that Covid-19 vaccines could be harmful and has encouraged the use of unproven remedies such as steam inhalers and herbal medicine. “Vaccines are not good. If they were, then the white man would have brought vaccines for HIV/AIDS,” Mr Magufuli said last month. However, he has since acknowledged that Tanzania is being hit by coronavirus after a high-profile politician died of the virus’.⁸

Rationing and Vaccines

There is not enough healthcare to provide everyone with everything. Choices must be made and the question is by whom. This is a reality and is a constant source of tension. It was highlighted in the UK and Europe during the first wave of the pandemic and, although there were more resources during the second, it still was a consideration. If there are 15 ventilators and 25 patients who need them then who has priority. These are big questions faced by healthcare providers, especially those in the public sector. I find it hard to have conversations on this, too often it becomes heated with economic pragmatism placed in opposition to human rights and ethics.

I was delighted to come across an excellent, short article addressing this, and quote it at length.⁹ Written by nephrologists (kidney specialists), they note:

“the circumstances of resource scarcity highlighted by COVID-19 are familiar to nephrologists in LMICs .. faced with the epidemic of chronic kidney disease, which claims more lives each year than COVID-19 likely will, although less acutely. With limited availability of kidney replacement therapy (KRT; that is, dialysis and transplantation), difficult moral and ethical decisions regarding who should be prioritized for access must be made regularly…

Rationing of scarce health-care resources is distressing. Clinicians therefore require clear guidance, which should be developed systematically and transparently through multi-stakeholder engagement. Rationing is seldom required in high-income settings but is often necessary in low-income settings. Global solidarity and health system strengthening are required to reduce the need for rationing. … The COVID-19 pandemic … has forced planning and/or the implementation of health-care rationing almost universally.

Rationing has always carried negative connotations and, until the current crisis, its mention would have at least raised some eyebrows, if not invited outright condemnation by members of civil society and many health-care workers. However, the need to potentially restrict the allocation of health-care resources in face of the relentless onslaught of COVID-19 has been widely accepted as a required response to the pandemic. The matter-of-fact development of recommendations for prioritized triaging of critically ill patients based on ethical principles gained rapid acceptance…. this situation reflects the everyday reality of the majority of the world’s population, who live in low- and middle-income countries (LMICs)¹⁰ … An implicit global double standard has long upheld that rationing was unacceptable for HICs but was tolerable for LMICs.”

The experience in Italy is instructive. Triage guidelines had to be developed for health-care workers, and to introduce some objectivity and transparency in decision-making. The guidelines were based on a utilitarian approach to distributive justice, which aimed to maximize benefit (that is, lives saved or life-years saved) while treating patients with equal needs equally. Mortality, age and comorbidities were the de facto main determinants restricting access to ICUs.”

The article, all of which is worth a careful read goes on to discuss the situation in Africa and then notes

“An ethical framework for the allocation of scarce health-care resources, especially in pandemic emergency situations, should be developed between nations, led by the WHO. African nations and other LIMCs must also do their part and ensure that they become more self-reliant for critical goods and services by promoting and supporting local investment”.

Vaccines are a scarce resource and are probably the only way out of the lockdown. The question of who gets what and when is increasingly a debate, and potentially, this is well covered by Priti Patnaik from Geneva Health Files.¹¹ Two paragraphs from the last issue provide a teaser:

“‘Held to ransom’: Pfizer demands governments gamble with state assets to secure vaccine deal: The Bureau of Investigative Journalism”

and

“Officials from Argentina and the other Latin American country, which cannot be named as it has signed a confidentiality agreement with Pfizer, said the company’s negotiators demanded additional indemnity against any civil claims citizens might file if they experienced adverse effects after being inoculated.”

The Bloomberg vaccine tracker shows that Israel leads the world in the administration of vaccines followed by the Seychelles and the United Arab Emirates (UAE). As of yesterday, the UK had delivered 19 million doses giving a coverage of 28 doses per 100 people. The USA has delivered 65 million doses at 19.59 per 100 people. Apart from Chile, every other country in the world has given fewer than 10 doses per 100 people, there is a long way to go.

Vaccination is crucial and forms an important part of the route map revealed by Boris Johnson on 22nd February. This spells out how the English nation will ease and finally lift restrictions and will be ‘driven by data not dates’. It seems sensible, provided he does follow it.¹² Scotland, Wales and Northern Ireland will have their own paths to the end of lockdown.

Conclusion

The discovery phase of the pandemic will soon be over. That is not to say scientists will stop working, improving the treatments and vaccines we have, and making important new breakthroughs. Of course, this will continue. The medical phase is in full swing with millions of patients being treated and hundreds of millions being vaccinated. Here, the challenge is to ensure the people who need to be prioritised actually get the vaccinations. I think we might then need to ask if everybody does need it? I don’t know, and I am not seeing any discussion of this. The next stage is rebuilding our societies: giving people back their lives, ensuring they have basic needs and asking what more is needed.

Thank you for reading, reposting and providing comments. What I write is public domain so please share, forward and disseminate. My contact is: awhiteside@balsillieschool.ca

---

1. Sir James Paget, 1814 – 1899, was born nearby in Great Yarmouth. He was known as the father of British pathology, as a scientist, and for being an early supporter of women becoming doctors.
2. Johns Hopkins Coronavirus Resource Centre https://coronavirus.jhu.edu/
3. https://coronavirus.data.gov.uk accessed 23rd February 2021
4. Ourworldindata.org/covid-deaths
5. It must be remembered this is from a low base.
6. Siddhartha Mukherjee, ‘Why Does the Pandemic Seem to Be Hitting Some Countries Harder Than Others? While the virus has ravaged rich nations, reported death rates in poorer ones remain relatively low. What probing this epidemiological mystery can tell us about global health’. Coronavirus Chronicles, March 1, 2021 Issue online February 22, 2021 https://www.newyorker.com/magazine/2021/03/01/why-does-the-pandemic-seem-to-be-hitting-some-countries-harder-than-others
7. https://www.samrc.ac.za/reports/report-weekly-deaths-south-africa accessed 23rd February 2021
8. https://www.telegraph.co.uk/global-health/science-and-disease/flourishing-anti-vax-movement-threatens-derail-immunisation
9. Mohammed R. Moosa & Valerie A. Luyckx, ‘The realities of rationing in health care,’ Nature Reviews Nephrology (2021) Published: 15 February 2021 https://www.nature.com/articles/s41581-021-00404-8
10. LMIC: Low and/or middle income country
11. https://genevahealthfiles.substack.com/p/limits-to-vaccine-diplomacy-trips
12. https://www.gov.uk/government/publications/covid-19-response-spring-2021/covid-19-response-spring-2021-summary